Provider Demographics
NPI:1831939404
Name:RYAN, TARA JEAN (PHD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:JEAN
Last Name:RYAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 CENTER ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2669
Mailing Address - Country:US
Mailing Address - Phone:503-979-1881
Mailing Address - Fax:
Practice Address - Street 1:2600 CENTER ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2669
Practice Address - Country:US
Practice Address - Phone:503-979-1881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0005795103TF0200X
OR3603103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic